Although the role of the tumor suppressor gene p53 is well known in cancer, recent studies have highlighted a fundamental role for p53 in regulating cells in the advanced atherosclerotic plaque, the major cause of heart attacks and stroke. In particular, p53 is activated in the complex environment of the plaque, in part by DNA damage within the lesion, and regulates growth arrest, cell senescence and apoptosis of vascular smooth muscle cells (VSMCs). The role of endogenous p53 has been determined using p53 knockout in mice developing advanced atherosclerosis, using bone marrow transplant to separate effects on blood cells from vessel wall cells. These studies have produced apparently contradictory and surprising results. In particular, recent studies have identified a role for endogenous p53 in protection of VSMCs from apoptosis, trans-differentiation of bone marrow stromal cells into VSMCs in atherosclerosis, and altering the mode of cell death in the plaque.